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Skin and Soft Tissue Infections Following Marine Injuries

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Skin and Soft Tissue Infections Following Marine Injuries CHAPTER 6 Skin and Soft Tissue Infections Following Marine Injuries V. Savini, R. Marrollo, R. Nigro, C. Fusella, P. Fazii Spirito Santo Hospital, Pescara, Italy 1. INTRODUCTION Bacterial diseases following aquatic injuries occur frequently worldwide and usually develop on the extremities of fishermen and vacationers, who are exposed to freshwater and saltwater.1,2 Though plenty of bacterial species have been isolated from marine lesions, superficial soft tissue and invasive systemic infections after aquatic injuries and exposures are related to a restricted number of microorganisms including, in alphabetical order, Aeromonas hydrophila, Chromobacterium violaceum, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Myco- bacterium fortuitum, Mycobacterium marinum, Shewanella species, Streptococcus iniae, and Vibrio vulnificus.1,2 In particular, skin disorders represent the third most common cause of morbidity in returning travelers and are usually represented by bacterial infections.3–12 Bacterial skin and soft tissue infectious conditions in travelers often follow insect bites and can show a wide range of clinical pictures including impetigo, ecthyma, erysipelas, abscesses, necro- tizing cellulitis, myonecrosis.3–12 In general, even minor abrasions and lacerations sustained in marine waters should be considered potentially contaminated with marine bacteria.3–12 Despite variability of the causative agents and outcomes, the initial presentations of skin and soft tissue infections (SSTIs) complicating marine injuries are similar to those occurring after terrestrial exposures and usually include erysipelas, impetigo, cellulitis, and necrotizing infections.3 Erysipelas is characterized by fiery red, tender, painful plaques showing well-demarcated edges, and, though Streptococcus pyogenes is the major agent of this pro- cess, E. rhusiopathiae infections typically cause erysipeloid displays.3 Impetigo is initially characterized by bullous lesions and is usually due to Staphylococcus aureus or S. pyogenes. Nevertheless, S. iniae infections are also characterized by either impetigo or cellulitis.3 Marine necrotizing infections can be either monomicrobial or polymicrobial. In both cases, the process may advance quickly to necrotizing fasciitis and myonecrosis, especially The Microbiology of Skin, Soft Tissue, Bone and Joint Infections © 2017 Elsevier Inc. ISSN 2451-9006, http://dx.doi.org/10.1016/B978-0-12-811079-9.00006-9 All rights reserved. 93 94 The Microbiology of Skin, Soft Tissue, Bone and Joint Infections in patients with underlying chronic wounds, such as chronic dermatoses and venous stasis ulcers; otherwise this may occur in immunocompromised hosts on corticosteroid treat- ment or showing liver disease, diabetes mellitus, HIV infection, or cancer.3 Grossly contaminated or infected lesions and all puncture wounds should be cultured or biopsied immediately and, although an empirical antibiotic approach is warranted, all definitive antimicrobial therapy should be targeted on precise pathogen identification and in vitro susceptibility testing.3 The aim of this chapter is to draw a picture of salient aspects of marine water environment-related SSTIs, by focusing on major bacteria behind the curtain of these clin- ical conditions and on their habitats, microbiological features, and diseases they may cause. 2. EPIDEMIOLOGY After acute and chronic management of SSTIs in tsunami survivors with contaminated aquatic injuries, the early predominance of Gram-negative aquatic organisms emerged in early-onset infections, while rapidly growing mycobacteria are mostly agents of sea-related late-onset infectious syndromes.1,2 Although Gram-positive bacteria such as Staphylococcus aureus and streptococci, as well as Pseudomonas aeruginosa (Gram-negative) and several other bacterial species, have been isolated from infected minor marine wounds, some of the more uniquely marine bacterial pathogens observed after more severe aquatic injuries include Aeromonas and Shewanella species, Chromobacterium violaceum, Edwardsiella tarda, Vibrio vulnificus and marine mycobacteria.1,2 Nonetheless, an empiric approach against SSTIs that develop shortly after marine water exposure should still cover Streptococcus pyogenes and S. aureus, not only marine water-related organisms.1,2 Then, in general, treatment could include a first-generation cephalosporin or clinda- mycin combined with levofloxacin or ciprofloxacin plus doxycycline (if an increased risk for acquiring V. vulnificus exists).1,2 2.1 Aeromonas Species The genus Aeromonas includes Gram-negative bacilli inhabiting warm soil together with fresh and brackish waters worldwide and behaving both as aquatic animal commensals and pathogens.13 Most can produce enterotoxins and hemolysins, thus causing acute hemorrhagic diar- rheal syndrome and invasive SSTIs in both immunocompetent and immunocompro- mised hosts exposed to an aquatic environment, including near-drowning.13 Aeromonas wound infections may develop after freshwater traumatic lesions, i.e., alli- gator, fish, snake and leech bites; infected injuries usually involve extremities or other bodily sites where open wounds were immersed in contaminated freshwater in warmer Marine Environment-Related Infections 95 months.13,14 Within 24 h, erythema, edema and purulent discharge (indistinguishable from streptococcal cellulitis) can be observed.3 There may be fever and progression to invasive infections, especially in the immunocompromised population, with necrotizing fasciitis, necrotizing myositis and bone involvement.13,14 Although most Aeromonas SSTIs follow aquatic immersions, an outbreak of A. hydrophila wound infections after mud exposure in 26 football players was reported in 2002. None of the players had any immunocompromising underlying condition, and all recovered with antibiotics.14 In general, Aeromonas strains from human infections are susceptible to aminoglyco- sides, carbapenems, fluoroquinolones, aztreonam, tetracyclines, as well as third- and fourth-generation cephalosporins, while variable levels of activity have been reported for cotrimoxazole.15 In addition to wound drainage and debridement, Aeromonas wound infections should be faced initially with either a third-generation cephalosporin or a fluoroquinolone, pos- sibly combined with an aminoglycoside pending antibiotic susceptibility testing and cul- ture results.15,16 2.2 Chromobacterium violaceum Chromobacterium violaceum is a Gram-negative, aerobic rod, behaving as a ubiquitous sap- rophyte in soil and water in tropical and subtropical regions all over the world.17,18 In spite of its wide geographical distribution, it is a low-grade pathogen that is responsible for few cases of infection in immunocompetent people and is often dismissed as a con- taminant at examination of cultures.17 The organism is presumptively recognized by the violet color of colonies it forms, with nonpigmented strains being less common.17–19 Most cases occur in temperate and tropical regions and are characterized by high fatal- ity rates in immunocompromised patients and the possibility of neutrophil impairment should be taken into consideration when managing patients with fulminant infections of C. violaceum.20 The portal of entry is generally a skin lesion secondary to a laceration or fish bite, followed by contamination with brackish or stagnant water. An ulcerated lesion with a bluish purulent discharge is usually observed at the initial injury site with regional swelling on an extremity. In the following days, bacteremia may occur, more commonly in the immunocompromised hosts, with disseminated macular cutaneous lesions progres- sing to abscesses; these may also involve bone, liver, and lung as well as spleen. Due to the rarity of this infection, availability of treatment recommendations is still lacking.18,19 C. violaceum is usually susceptible to aminoglycosides, carbapenems, chlorampheni- col, cotrimoxazole, fluoroquinolones and tetracyclines, but resistant to most penicillins and cephalosporins.18,19 Because of high mortality rates, treatment of suspected C. violaceum infections should start immediately and be based on drainage of purulent 96 The Microbiology of Skin, Soft Tissue, Bone and Joint Infections abscesses and empiric combination of intravenous antibiotics, which will be narrowed after susceptibility testing results are provided.19 2.3 Edwardsiella tarda Edwardsiella tarda is a Gram-negative rod-shaped organism belonging to the family Enter- obacteriaceae; it notoriously behaves as an aquaculture pathogen and causes emphysema- tous putrefactive disease in catfish.21 Extraintestinal E. tarda infections are uncommon compared with intestinal ones, and are frequently represented by wound abscesses needing surgical incision and drainage in patients with marine exposures or injuries; extensive myonecrosis and fatal septic shock may develop in immunocompromised hosts, especially those with chronic epatopathy.22 2.4 Shewanella Species The genus Shewanella includes saprophytic Gram-negative microorganisms inhabiting warm and temperate regions worldwide and which are part of the marine environment microflora. More than 50 species of Shewanella have been classified thus far, all of which produce yellowish-brown pigmented and mucoid colonies releasing hydrogen sulfide in culture.23,24 Several Shewanella species have been recently known to be emerging agents of soft tissue and invasive infections following seawater exposure, and these include Shewanella algae (which is the most common), Shewanella
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